OMB Appendix D Postal survey

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number.  The OMB Control Number for this information collection is 2120-XXXX which has been approved for collection of voluntary responses only.  Public reporting for this collection of information is estimated to be 8.25 minutes to complete the postal survey and 2 hours and 33 minutes of active participation across 5 study days to complete the field study.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Donald Scata, FAA-AEE-100, 800 Independence Ave. SW, Washington, DC 20591, or by email at SleepStudy@faa.gov.

OMB #2120-XXXX Exp. XX/XX/XXXX

Instructions for Completing the Survey

The survey can be completed online or by filling out the survey on the following pages. It will take you approximately 10 minutes to complete.

If You Choose to Complete the Online Survey:

• Go to the following link: <<URL>>

• Enter the access code: <<access code>>

• Enter the following number for your Subject ID: <<individual subject ID>>

• Questions are either multiple choice or fill in the blank

• Click on the ‘SUBMIT’ button when finished

• The survey can also be accessed on your smart phone or tablet using the QR code below:

If You Choose to Complete the Paper Survey:

• Please mark all answers clearly and return the completed survey using the included return envelope

• If the question is multiple choice, mark your answer by placing an x

in the box: ☒

• If there are no response alternatives listed, write in your response in the provided space

For BOTH versions of the survey only select one answer except where indicated.

Todays date: ____________________

Q1. During the last month or so, how would you rate your sleep quality overall?
Very good ↓	Fairly good ↓	Neither good nor bad ↓	Fairly bad ↓	Very bad ↓
□	□	□	□	□

Q2. Select the response that best reflects how often you have taken medicine (prescribed or “over the counter”) to help you sleep during the last month or so.
Not during the past month ↓	Less than once a week ↓	Once or twice a week ↓	Three or more times a week ↓
□	□	□	□

Q3. How strongly do you agree or disagree with the statement “I am sensitive to noise”?
Strongly disagree 1 ↓	2 ↓	3 ↓	4 ↓	Strongly agree 5 ↓
□	□	□	□	□

Q4. Thinking about the last 12 months or so, when you are here at home, how much does noise from aircraft bother, disturb or annoy you?
Not at all ↓	Slightly ↓	Moderately ↓	Very ↓	Extremely ↓
□	□	□	□	□

Q5. Thinking about the last 12 months or so, when you are here at home, how much does noise from aircraft disturb your sleep?
Not at all ↓	Slightly ↓	Moderately ↓	Very ↓	Extremely ↓
□	□	□	□	□

Q6. Now considering how you feel about everything in your neighborhood, how would you rate your neighborhood as a place to live on a scale from 1 to 5 where 1 is best and 5 is worst?
Best 1 ↓	2 ↓	3 ↓	4 ↓	Worst 5 ↓
□	□	□	□	□

Q7. In general, would you say your health is…?
Excellent ↓	Very good ↓	Good ↓	Fair ↓	Poor ↓
□	□	□	□	□

Q8. Have you ever been diagnosed by a health professional with any of the following sleep disorders (mark all that apply)?
□ Sleep apnea	□ Narcolepsy	□ Restless leg syndrome
□ Periodic limb movement syndrome	□ Insomnia	□ None
□ Other (please specify): _____________________________________________________________

Q9. Do you have any problems or difficulties with your sense of hearing?

□ Yes

□ No

Q10. Have you ever been diagnosed by a health professional with any of the following conditions (mark all that apply)?
□ Hypertension/High blood pressure	□ Arrhythmia/Irregular heartbeat	□ Heart disease
□ Diabetes	□ Cancer	□ None

Q11. What is your current employment status?

□ Employed (working mostly from home)

□ Employed (working mostly away from home)

□ Unemployed/searching for a job

□ Student

□ Retired

□ Homemaker

□ Other

Q12. What is the highest degree or level of school you have completed?

□ Less than high school

□ High school graduate, including equivalency

□ Some college credit, no degree

□ Bachelor’s degree

□ Graduate or professional degree

Q13. What was your total household income last year?

□ Less than $10,000

□ $10,000 to $14,999

□ $15,000 to $24,999

□ $25,000 to $34,999

□ $35,000 to $49,999

□ $50,000 to $74,999

□ $75,000 to $99,999

□ $100,000 to $149,999

□ $150,000 or more

□ Prefer not to answer

Q14. If currently employed, does your job require overnight shift work? (Overnight shift work refers to work for at least 4 hours between 00:00 midnight to 06:00 am in the morning)

□ Yes

□ No

Q15. What is your Ethnicity?

□ Hispanic or Latino

□ Not Hispanic or Latino

Q16. What is your race? Mark all that apply.
□ American Indian or Alaska Native	□ Asian
□ Black or African American	□ Native Hawaiian or Other Pacific Islander
□ White	□ Prefer not to answer
□ Other (please specify): ____________________________________________________________

Q17. How long have you lived at your current residence?

□ Less than 1 year

□ 1 year or more but less than 5 years

□ 5 to 10 years

□ More than 10 years

Q18. How many people (including yourself) reside in this household?

__________________

Q19. Is there someone living in your home that frequently requires your care during the night?

□ Yes

□ No

Q20. What is your sex:

□ Male

□ Female

Q21. What is your age:

____________ (years)

Q22. What is your height?	_____________feet ____________inches
Q23. What is your weight?	_____________________lbs

Q24. Any other comments?	________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Q25. Are you interested in taking part in the in-home sleep study, and do you give your permission for the study team to contact you either by phone or email?

□ Yes

□ No

If you are interested in the in-home study, please provide your contact details below.

First Name (Print):	______________________________________________________
Last Name (Print):	______________________________________________________
Email Address:	______________________________________________________
Phone # (Land-line):	______________________________________________________
Phone # (Cell):	______________________________________________________